Musings in the life of an internist, cardiologist and cardiac electrophysiologist.

Wednesday, April 30, 2008

Where Have All The Residents Gone?

Last night - a code - complete heart block. I was called it to place a temporary pacing wire in the ICU. Little time. Stress. Need to prepare the field. Gloves, does anyone have gloves? Could we prep the area? You have the central line kit? Could I get another set of hands?

Then I realized something. The residents who had so carefully run the initial code and get the patient to the ICU had vanished. Why? Don't they want to learn how to start a central line, or at least see one placed? Where are they?

After the dust settled, I came to realize what had happened.

So to them and the medical teachers everywhere, I dedicate my parody of Pete Seeger and Joe Hickerson's "Where Have All the Flowers Gone" popularized by Peter, Paul and Mary and Joan Baez:

Where Have All the Residents Gone?

Where have all the residents gone, long time passing?Where have all the residents gone, long time ago?Where have all the residents gone?They’ve gone to the keyboards everyone.When will they ever learn?When will they ever learn?

Where have all the keyboards gone, long time passing?Where have all the keyboards gone, long time ago?Where have all the keyboards gone?They’re now in the hospitals everyone.When will they ever learn?When will they ever learn?

Where have all the hospitals gone, long time passing?Where have all the hospitals gone, long time ago?Where have all the hospitals gone?They’ve gone to the hospitalists, everyone.When will they ever learn?When will they ever learn?

Where have all the hospitalists gone, long time passing?Where have all the hospitalists gone, long time ago?Where have all the hospitalists gone?Consulting the specialists, everyone.When will they ever learn?When will they ever learn?

Where have all the specialists gone, long time passing?Where have all the specialists gone, long time ago.Where have all the specialists gone?They’re planning retirement, everyone.When will they ever learn? When will they ever learn?

Where have all the retirees gone, long time passing?Where have all the retirees gone, long time ago?Where have all the retirees gone?They’re treated by residents, everyone.When will they ever learn?When will they ever learn?

Wes:Instead of your snotty elitist parody why didn't you bother to ASK. Maybe they were in the ER admitting the next ICU patient for the night or in another part of the ICU dealing with another patient (after all there are other patients in the ICU besides yours) or in another part of the hospital evaluating likely transfers. The point is YOU DON'T KNOW. Yet you put them down. Your professionalism is underwhelming. Additionally, by the end of my residency I could count the number of attendings on ONE HAND that were as proficient as I was in placing central lines (not TVP). Academic attendings rarely place central lines and you know it pal. Thanks for reminding me it is pompous attitudes like yours that made me avoid the "Ivory Towers" of medicine like the plague when I finished residency (long before the 80 hour workd week thank you). Grow up dude, your trainees would appreciate it. .

Please, get over yourself. You were the one who was not there when I placed the line that evening. You were not there to observe the resident sitting at the computer in the central station of the ICU as the nurses noted the patient’s heart rate to be 20-30 and the systolic blood pressure to be 60. I DID know, in this case. The gumption of yours to think that none of us have been residents in the same circumstance before is mind-boggling to me. To suggest that anyone should require that the attending “ask” them to join them in stabilizing the patient in such a situation is ludicrous – most residents I know would be able assess the urgency of the situation and spring to action rather than bask in their narcissistic revelry of their central line-placing prowess. If you can pull yourself away from the mirror, consider for a minute if you were that patient. How many of your fellow-residents with whom you trained do you feel would be able to confidently place a central line in your neck? Probably very few (and that was before the 80-hour work week restrictions).

And why is that?

Well certainly, not everyone has the inclination to become an invasive physician and they decide to opt out of that tract. I have no problem with that. But for those residents who decide on a more “surgical” area of medicine, the medico-legal environment, coupled with the resident’s patient volume caps, limits the number of opportunities for such moments to present themselves for real-life, hands-on teaching. So why wouldn’t those residents want to participate every chance they get? I can’t say. Perhaps it is the many hats they try to wear on call, the bureaucratic documentation requirements to prove their existence, whatever. But more and more I see residents (and ALL doctors) making rounds at a computer, rather than the patient’s bedside. All too often, decisions made are based on test results and without adequately communicating with patients. The easy information flow that presents itself on a computer screen does not require patient interaction – hospitals and health policy administrators bask in this “efficiency.”

But at the end of the day, it’s not about efficiency, or central line placing prowess, it’s about the patient – the one your hands and mine as the central line is placed. None of us should ever feel we’re above constantly trying to improve our skills. Ever. So if this parody pissed you off and opens a few more eyes, then, good.

The only eyes opened show that you are that you are a pompous academic. It's about the patient? Well, no shit. thanks for the statement ofthe obvious pal. Did you use this as a "teaching moment" for the resident (ie. Maybe a sys BP in the 60's and a HR deserves your bedside attention?) I would have, instead of a blog parody. That is what TEACHERS ARE SUPPOSED TO DO. Not make fun of the residents on a blog (which they probably will never read). You tell me, is that in the interest of the patient? As far as IJ's they are used preferentially to femoral's for infectious related reasons. We were ALL proficient in placing them (unlike the attendings). So take YOUR attitude elsewhere and get over YOURSELF. A real teacher doesn't make fun of their trainees on a blog. They show them what they are doing wrong for pete's sake. The simple fact is those lazyass "residents" do the majority of your non-invasive scutwork. I have spent my whole career (since residency) in private practice I damn well know the differnece between academic attendings and me. Frankly, I am not impressed.

What is the most remarkable is how much things have changed. The RN's perspective is this. Years ago on the patient care floors, there were always residents reviewing PAPER charts at the nursing station and you would grab one if there was an emergency. Now they are eletronically charting in a "computer lab" off the floor.When they were on the floor and we would discuss patient concerns.Now I have been told that to save time it is best if I "text page" them my concern and they will electronically enter an order as necessary. Progress?

Sounds to me like you need adequate computor space on the floor. That stated I still think the 80 hr work week is a good idea. The simple fact is working nascent docs (who frankly need time to read about what they are looking at) to the point of exhaustion is crazy. Anybody know who Libby Zion was? Tell me, was that good patient care? I trained long before the RRC rules and I will always think the old process is STUPID. Frankly the 80 hr work week hasn't changed my practice one bit as a private practice attending. But the fact is I am experienced and (usually) know what I am looking at and when I need help. It's is a little different being an R1 or R2 at 6:00 PM after being up for 36 hours straight and your "hardworking" academic attending has gone home for the day. I hear the academics whine about the RRC rules (the unfairness of it, having to actually get it in the middle of the night to admit your own patient!!!) but frankly, historically I have seen alot of laziness among academic (and VA) attendings. It's simply about time they started acting like teachers they signed on to be instead of writing stupid little songs denigrating their trainess.

fwiw, although i certainly think academic attendings are some of the most pompous, lazy people i have ever met, i do have a hard time not criticizing residents who chose not to actively participating in the care of an acutely ill patient. however as one who naively sprung into action for every code and every line, i can tell you after the fact that all the lawsuits those high risk cases resulted in follow you around forever. even if you are ultimately dismissed. it sucks when you credential at a new hospital.

finally, i'm not sure dr wes's practice fits my view of a traditional academic practice since he was there doing the procedure. when i trained, i would never have been able to find an attending at night. i mean never ever not in a million years except in the er.

The idea of a more than 80 hour work week has never seemed, to me, to be consistent with a healthy learning environment, but more like a cost cutting hazing ritual.

I did not get the impression that Dr. Wes as much criticizing the residents as criticizing where the whole health care system seems to be headed.

I am surprised that a reader would have the arrogance and foolishness to assume that Dr. Wes had not checked the accuracy of what the residents were doing. I did wonder if that is what they were actually doing, but would have asked, first. If he answered that he had not checked, then some criticism might be appropriate.

I could leap to the conclusion that anonymous the first (and possibly second, but there may be a whole posse of them) approaches diagnosis the same way he, or she, approaches blog comments. This would clearly be an error in my judgment, but it would be consistent with anonymous I's commenting.

Sometimes teaching is not about making the student feel good about what the student did, but about having the student remember the right way to do things when the right way needs to be remembered.

Sorry:I tend to agree with the other anon's on this one. I would expect an attending doctor would pull the resident aside and give him a long lecture the importance of one on one evaluation in a situation described as above after the pateint had been stabilized. Possibly that Dr Wes did this but there is no mention of it in his initial comment or followup comments which makes me think he did not. That is not appropriate conduct for an attending doctor. IMO watching not watching the invasive cardiologist place the line/pacer is a secondary issue. The central issue is the resident was not evaluating the patient in a precode situation and the attending doctor did not instruct him on the error of his ways. Something to think about Dr. Wes.

You provide more assumptions about what happened. If you do not know what did happen, you should find out before making accusations.

There was nothing in the post to indicate what was done. You state that you do not have direct knowledge of what was done. You then leap to the conclusion that seems to satisfy your feelings about attending physicians.

This is not logical.

I agree that the residents should have been addressed individually.

To follow your logic, I should praise Dr. Wes for doing such a good job of individually addressing the residents' actions after tracking them to their floors.

Why let the facts, or lack of facts, get in the way of a good story?

I do not know how this was handled. Therefore, to assume I know how it was handled and accuse or praise, without any knowledge of what really happened, is foolish.

Where is there any mention of the assessment in the original post? Maybe these residents did a good assessment.

The idea that this is public humiliation of these anonymous residents, who may never read this blog, is also taking things a bit farther than warranted.

The comments on this post have a much more negative tone than anything I read in the original post. These comments suggest a lack of objectivity that a good medical education should have killed off.

Please folks, I have not intended to offend. As a physician responsible for teaching housestaff my entire career, I am fully cognisant of the feedback loop integral to teaching during moments like these. Many hours have been spent with housestaff regarding the management issues involved in this case. But beyond this, I cannot comment further - to do so would require details that would threaten patient (and resident) confidentiality.

For the record, my practice is very "hands on" - much more like private practice (which I have experienced, by the way) than some "ivory tower" academic position implied by others - where the hell that came from I cannot say. But I also am not an anonymous blogger, and think carefully about what I say - and teach - despite what others may have perceived from this post.

OK WesThan I think "for the record" this thread would have been better off not posted. Like you (and unlike medic) I have overseen resident education. Given the impression you left (a resident ignoring a critically ill patient), it should have been handled behind closed doors with you, the resident in question, and possible the residency director. You have alluded to this yourself by your belated concern of patient/resident privacy. It really has no place on a public blog. End of story.

About Me

Westby G. Fisher, MD, FACC is a board certified internist, cardiologist, and cardiac electrophysiologist (doctor specializing in heart rhythm disorders) practicing at NorthShore University HealthSystem in Evanston, IL, USA and is a Clinical Associate Professor of Medicine at University of Chicago's Pritzker School of Medicine. He entered the blog-o-sphere in November, 2005.
DISCLAIMER: The opinions expressed in this blog are strictly the those of the author(s) and should not be construed as the opinion(s) or policy(ies) of NorthShore University HealthSystem, nor recommendations for your care or anyone else's. Please seek professional guidance instead.